Form Ct-31 - Cigarette And Unaffi Xed Stamp Inventory Report For Resident Distributors Page 2
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2Part II. Unaffi xed Connecticut Cigarette Tax Stamps or Decals
The total of Form CT-31, Part II, should agree with the amount reported on Line 4 of Form CT-15.
For the month of __________________________________ 20 ______
Quantity of Connecticut Cigarette
For DRS Use Only
Tax Stamps or Decals
Face Value of Each
Total
$
@ 3.40
@ 4.25
$
Total face value
$
Declaration: I declare under penalty of law that I have examined this return or document (including any accompanying schedules and state-
ments) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand that the penalty for willfully delivering a
false return or document to the Department of Revenue Services (DRS) is a fi ne of not more than $5,000, imprisonment for not more than fi ve
years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Authorized signature
Date
Print name
Title
CT-31 Back (Rev. 07/11)
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